Electrosurgery Injuries in the Operating Room

Cemalettin Celebi, MD;Yener Demirtas, MD;Suhan Ayhan, MD;Reha Yavuzer, MD;Osman Latifoglu, MD

Electrosurgery generators or the so called cautery devices were introduced in 1927 by Harvey Cushing, a neurosurgeon, and William T. Bovie, a physicist, who developed the system utilizing the principles invented by Hertz in 1886. The use of this fool-proof instrument became widespread year by year, assisted in the advancement of surgery, and today, it is the most frequently used energy source in the operating rooms worldwide as a major surgical element in all kinds of surgery. Although recently developed technology products ensured electrosurgery to be performed in a safer manner, they did not reduce the significance of preventive measures that should be taken for safety of the patient and the surgeon in electrosurgery applications.1-3

In this study, we present the occurrence of skin injuries in patients and surgeons during electrosurgery along with a review of basic electrosurgical principles which are supposed to guide surgeons through appropriate, effective and uncomplicated electrosurgery applications.

Material and Methods: We determined and documented all electrosurgery injuries occurring in our operating rooms in the last 12 months. We revealed causative factors and preventive measures to minimize these injuries. For this purpose, we analyzed the injuries, reviewed the literature and had interviews with major electrosurgery generator manufacturers.

Results and Case Reports: We encountered 10 electrosurgery injuries, six of which were glove bites of the surgeons that are painful accidents experienced by many of us. Five distinct mechanisms were identified for these burns. Four of the injuries were different electrosurgery complications faced by the patients, one of which was eventually fatal. These complications included two alternative site burns, one plate burn and one laparoscopic direct coupling injury to the bowel.

Case 1: A 27-year-old man complained of pain in his right chest immediately after a craniofacial surgery that lasted 3 hours. Upon inspection, a 4x6 cm lesion of second degree burn was detected (Fig.1). Dessication with monopolar electrosurgery on high power “coag” mode was used in this patient for hemostasis during bicoronal incision of the scalp. The localization and the shape of the lesion resembled an alternative site burn caused by an ECG monitor electrode. Actually, it is impossible to confirm the real origin of such a wound, but the most probable scenario is the induction of a stray current by a spoiled electrode, possibly because of wetness. The sticky electrodes used today are definitely safer than the historical pinned ones; nevertheless they are not free of risk. Theoretically, it is likely for any conductor that is in contact with the patient and the ground (the wet surgical dressing in the case) to act as a short-cut for the high voltage “coag” current and cause a skin burn.1 Although it was found to be problem free retrospectively, any trouble in the ECG monitor would have facilitated the incident.

Case 2:Forty years old female was seen for a skin color change at her flank four days after a laparoscopic ovarian cystectomy. She was diagnosed to have a necrotizing soft tissue infection after a “finger test” and urgent debridement was performed. Exploration of the abdomen revealed the etiology; there was a perforation at the sigmoid colon. In spite of colostomy and adequate debridement, the patient was lost eventually. Histological evaluation of the resected bowel segment confirmed the thermal injury: it was a monopolar electrosurgery complication.

Case 3:Monopolar surgery on “coag” mode at 120 Watts was being utilizedduring an abdominal surgery. The surgeon who was handling the active electrode accidentally touched it to the hand of the assistant as the current was on. This high powered current rent the glove and caused a second degree burn. That is a typical “direct coupling” injury. Avoidance of high power on “coag” mode and activation of the electrode only when it is in contact with the tissue or the hemostat are the simple preventive measures.

Conclusion: Electrosurgery injuries in the operating room are not infrequent. We believe that the issue deserves attention, because a conceptual understanding of some basic principles is important to an adept use of the instruments and the prevention of stray current injuries.Besides, appropriate and effective use of electrosurgery is directly related to length of operation, blood loss, infection, pain and wound healing. We recognized that simple precautions would sufficiently eradicate these injuries and composed some suggestions for electrosurgery performers.

Figure 1: Second degree alternative site burn on the chest of the patient.

Figure 2: Retrograde necrotizing soft tissue infection secondary to bowel perforation as a complication of monopolar laparoscopic electrosurgery.

Figure 3: A glove bite encountered during electrosurgical dessication utilizing high power “coag” mode. High voltage current penetrated the glove and burned the skin.

References

Absten, GT. Practical electrosurgery for clinicians (Electrosurgery Professional Medical Education Association, Inc. Associate of the Caribbean Medical Association web site). September 2002. Available at: Accessed February 15, 2004
Ulmer, BC. The Valleylab Institute of Clinical Education electrosurgery continuing education module (Valleylab web site). July 2001. Available at: Accessed February 15, 2004.
Lee, TW, Chen, TM, Cheng, TY et al. Skin injury in the operating room. Injury. 29: 345, 1998.